Chapter 1: Quality Disclosure and Patient Switching: Evidence from the Dialysis Industry:In 2012, the Centers for Medicare & Medicaid Services (CMS) implemented the End Stage Renal Disease Quality Incentive Program (QIP) to improve information transparency between dialysis patients and their treatment center by publishing novel quality scores. How dialysis patients respond to these new scores is unclear. This paper explores the extent to which the publication of quality scores influences patients' likelihood of switching dialysis centers, and whether the salience of these scores induces a behavioral change in patients. My findings show that patients at centers with lower quality scores are significantly more likely to switch than those at high quality centers. Specifically, patients at centers with a published score in the 10th percentile are nearly 19% (1.10 percentage points) more likely to switch than patients at centers with a published score in the 90th percentile. Furthermore, patients who learn they are at a low-quality center when scores are published increase their likelihood of switching by over 1.18 percentage points, suggesting that patients respond to the salience of quality scores. These results show that increasing transparency around treatment quality can affect patient decision-making and improve provider-patient matching, with implications for patient welfare and resource allocation. Chapter 2: Patient Preference of Provider Influence: Variation in Health Care Spending Among Dialysis Patients: Dialysis patients spend a substantial amount of time interacting with the staff and peers at their dialysis center, making these environments a potentially important influence on patient behavior. In this paper, I use patient switching to disentangle the demand- and supply-side factors that influence general health care spending. Leveraging an event study design, I examine changes in non-dialysis medical spending before and after a patient switches to a new dialysis provider, relating these changes to the utilization patterns of their new peers. The results show that switchers experience an immediate and persistent change in non-dialysis spending. Point estimates suggest that dialysis centers account for between 37.6% and 61.2% of the variation in a patient's non-dialysis health care spending. The effects are strongest in spending categories with greater patient discretion, such as non-dialysis outpatient visits, suggesting that policies aimed at reducing costs may benefit from appropriate targeting. Chapter 3: Value-Based Purchasing and Payment Reductions: Dialysis Center Response to the End Stage Renal Disease Quality Incentive Program: The Centers for Medicare & Medicaid Services introduced the End Stage Renal Disease Quality Incentive Program in 2012 to improve the quality of dialysis services and reduce costs. A key feature of this program is the implementation of value-based purchasing, which reduces reimbursement to dialysis centers that perform poorly on quality metrics. This paper evaluates whether such payment penalties are effective at improving clinical quality. Using administrative data from Medicare, I compare penalized and non-penalized dialysis centers and estimate the effect of penalties on clinical quality using three empirical approaches: a two-way fixed effects difference-in-differences model, a dynamic event study, and a model allowing treatment effect heterogeneity. The results suggest that dialysis centers penalized for low quality exhibit sustained improvements in septic infections, lower mortality rates, and fewer hospitalizations. These findings support value-based purchasing as an effective tool to incentivize improvements in treatment quality.
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